Have you noticed anything strange going on in your chiropractic office? Specifically, are you experiencing a higher number of denials when billing therapy services? If so, you’re not alone. It’s a trend across the country, and we’ve summarized the basic information that you need to know.

Who Is Experiencing the Most Therapy Denials?

While healthcare providers across the country have been experiencing an increase in denials when billing therapy services, the numbers in certain states are higher. These include Illinois, Oklahoma and Texas – particularly for claims submitted to Blue Cross Blue Shield (BSCS) plans owned by Health Care Service Corporation (HCSC). Because HCSC also owns Blues plans in Montana and New Mexico, increased denials may be spiking there as well.

Why the Increase in Therapy Denials?

It was announced In August of 2017 that BCBS would:

“ … be implementing a code-auditing enhancement to its claim system. This software will help improve auditing of professional and outpatient facility claims that are submitted to BCBSIL by clinically validating modifiers submitted on such claims.”

Last fall, HCSC began using their new claim-editing software that focuses on the use of particular modifiers (i.e. 25, 59, and X{ESPU}). This caused claim rejections for multiple services using these modifiers. These rejections include both E/M services and CMT, regardless if physical therapy services are included.

As a result, claims using these modifiers are being denied at a high rate, and the reasons for the denials are inconsistent and confusing. For instance, as cited on the American Chiropractic Association’s (ACA) website:

  • In some cases, the denials state the modifiers are used inappropriately.
  • In other cases, providers have received letters stating their utilization of the modifier is higher than average.

For whatever the reason stated on the EOB, denials are based on the new claim editing software. A number of state professional associations are getting involved, striving to collaborate with the payer to find resolutions to these problems. Right now, the only option for chiropractors to dispute denials is to appeal – and keep appealing.

How Should You Appeal?

Appealing denied claims involves reviewing the denied claims and making sure that the service and documentation meet all the criteria for that payer. To learn more about the appeal process and how to write an appeal letter, click here.

What You Can Do Now.

If your practice is experiencing an increase in denials for billed therapy services, here’s what you can do:

  • Even though you know a denial is likely, continue billing these services with the appropriate modifiers.
  • Establish an appeal process in your practice and consistently appeal each claim that is improperly denied.
  • When you are notified of a denial, appeal by providing supporting information and an appeal letter.
  • Collaborate with your state association, if possible, in your attempts to resolve the problem.

We are happy to help your practice manage these and all other types of denials – that’s what we do!

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